Provider Demographics
NPI:1245217363
Name:MCCLEAN, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MCCLEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SHERMAN ST
Mailing Address - Street 2:STE 510
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-4400
Mailing Address - Country:US
Mailing Address - Phone:303-377-6825
Mailing Address - Fax:303-780-0787
Practice Address - Street 1:455 SHERMAN
Practice Address - Street 2:SUITE 510
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-4405
Practice Address - Country:US
Practice Address - Phone:303-377-6825
Practice Address - Fax:303-780-0787
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26141207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7612563Medicaid
WI82622200Medicaid
CO01261411Medicaid
MT3506685Medicaid
KS100121110AMedicaid
NE84113438513Medicaid
NML4939Medicaid
TX051284001Medicaid
CAXPY203733Medicaid
WY109201400Medicaid
WI82622200Medicaid
050003951Medicare PIN
NML4939Medicaid